Claims History Verification

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The Claims History Verification Form serves as a means for medical credentialing offices, practitioners, and hospitals to request claims histories on individuals that have applied/reapplied for staff membership, clinical privileges and/or permission to provide services at a facility. The form serves as a tool to collect necessary information about individuals requiring information for medical credentialing.

Who is requesting this claims history?

Medical Professional Information:

Medical Provider's Full Name

Other Names Used

Provider's Email

Provider's Credentials

Provider's Date of Birth (mm/dd/yyyy)

Provider's Last 4 Digits of SSN

Term Seeking Claims History For (Beginning what date to what date)

Third Party Medical Institution Information:

Institution's Name

Institution's Address

Institution's City

Institution's State

Institution's Zip Code

Requestor's Name

Requestor's Title

Requestor's Email

Requestor's Phone Number

Release Information:

If you are the Medical Provider, please confirm the release authorization below.

I authorize and request Saint Louis University to release information regarding any claims or actions for damages pending or closed. I hereby release from liability any and all individuals and organization that, in good faith and without malice, provide the information requested for the purpose of verifying my professional skills, competence, experience, qualifications and credentials.

Confirmation

If you are a Third-Party Medical Institution seeking a claims history, please attach a signed consent, release and compliance statement from the provider below.

Please attach a signed consent, release and compliance statement from the provider.

File attachments associated with the ticket.

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Notes

Other Fields

Your name

Your email address